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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3855_Библиотеки_им_академика_М_И_Перельмана
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28
A. iliaca communi
terial access to
E. Kaiser et al.
. Fig. 2.2 Overview of
the arterial supply to the
pelvis and leg
abdominal aorta
2
s
A. iliaca externa
internal iliac
inguinal
ligament
A. femoralis
(communis)
A. femoralis (superficialis)
profunda femoris
artery
Pulse of the femoral
artery Ar
the femoral artery
. Fig. 2.3 Puncture site before arterial puncture of the right femoral artery. (Thanks to R.Schräder)
Procedural Complications
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. Fig. 2.4 Radiological marking of the puncture site
over the femoral head
well- palpable inguinal ligament would always
be too high (Garrett etal. 2005). The femoral
artery to be punctured lies in projection on the
femoral head, so that it is helpful to mark the
puncture height, especially if large sheaths are
to be inserted. It has proved practical to take
a brief uoroscopy and then mark the puncture height with the local anaesthetic needle,
for example (. Fig. 2.4). Particularly when
using large-calibre sheaths, the exact puncture
site should be found beforehand and then the
artery punctured under ultrasound control
and, if necessary, the rst puncture made
with a micropuncture set and then gradually
dilated up to the actual sheath.
False Aneurysm
z
After arterial puncture of the right groin, clinical complaints may still occur on the day of
the examination or on the following days, even
though the puncture was completely benign at
rst glance. Patients then usually express pain
at the puncture site or notice a small, palpable, painful swelling. Discoloration of the
skin around the puncture site due to small or
even larger hematomas is not uncommon, but
is usually clinically insignicant.
In addition to these subcutaneously
located and partially organized hematomas,
it is important to distinguish clinically and
29
sonographically the false aneurysm, which
can also cause problems in the further clinical
course. The false aneurysm is an outpouching
of the blood vessel wall, which arises from an
injury to the intima and media of the vessel.
Initially, the adventitia always remains intact.
Morphologically, the false aneurysm is to
be distinguished from the true aneurysm, in
which all vessel wall layers are involved in the
bulging of the vessel and there is no intimal
and medial defect.
The diagnosis of a false aneurysm begins
with palpation of the groin, which often, but
not always, reveals a clearly palpable pulsation. With the stethoscope, a loud buzzing
and hissing is auscultated. This should be
taken as an opportunity to conrm the suspected diagnosis by duplex ultrasound. For
this purpose, the punctured vessel is probed
in two axes and, if pathological, a perfused
aneurysm sac with turbulent ow is detected
(.
Figs.2.5 and 2.6).
Further diagnostics are usually not necessary. However, the imaging should be performed by a trained hand and lead to a clear
statement.
The therapy of the false aneurysm consists
rst of all of a manual and very punctual compression on the aneurysm neck. This is done
under ultrasound guidance. The compression
should not be interrupted for 30min and then
a pressure bandage should be applied for 12h.
In many cases, the false aneurysm can be
successfully closed in this way. After removal
of the pressure dressing, the ndings are
checked again by duplex ultrasound. Manual
compression must be preferred to thrombin
injection if there is no experience with thrombin injection. In all other cases, thrombin
injection should be performed in the appropriate patient (Lönn etal. 2002; Danzi et al.
2005; Yao etal. 2008).
As an alternative to compression, the
aneurysm can be closed layer by layer by
injecting thrombin into the aneurysm sac,
which is very comfortable and safe for the
patient (Hofmann etal. 2007; Ferguson etal.
2001). Crucial to the safe feasibility of throm-
bin injection is the presence of a sufciently
narrow and long aneurysm neck. Aneurysms
with very wide and short necks are rather not
2
30
E. Kaiser et al.
2
. Fig. 2.5 Pseudoaneurysm 1
. Fig. 2.6 Pseudoaneurysm 2
Procedural Complications
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31
2
recommended for thrombin injection (Luedde
et al. 2007). In these, thrombin can easily
inadvertently enter the femoral artery and
occlude the vessel (D’Ayala etal. 2008; Bhat
and Chakraverty 2007; Stawicki and Hoey
2007).
For the thrombin injection you need:
5 Thrombin
5 Saline
5 20 G cannulas of different length
5 An insulin syringe
5 Sterile conditions
5 Duplex ultrasound
For the thrombin injection, the false aneurysm is visualized with the transducer and
then entered laterally into the aneurysm sac
with the cannula. From there, the aneurysm
sac is then closed layer by layer under visualization by dropwise thrombin administration. Bolus thrombin injection is also feasible
(Lewandowski etal. 2011). The success of the
procedure is conrmed and documented by
duplex ultrasound by arresting the turbulent
ow in the aneurysm sac (. Fig.2.7).
In our own patient population almost all
false aneurysms could be closed by thrombin
. Fig. 2.7 Thrombin injection
32
E. Kaiser et al.
injection. Only in a few cases surgical suturing
was necessary, especially when the primary
thrombin injection was not successful. In
2
these cases, a hidden vascular defect may play
a role and be the cause of unsuccessful thrombin injection (Sheiman and Mastromatteo
2003). Also, concomitant antiplatelet medica-
tion and obesity play a role in the tendency to
recurrence (Madaric etal. 2009). Nevertheless,
if a hidden vascular defect is excluded, further thrombin injection can also be successfully performed (Edgerton et al. 2002).
Complications of compression therapy, such
as necrosis of the skin, are the absolute exception. If embolization occurs in the course of
thrombin injection, intra-arterial lysis is also
available as a therapeutic option in addition
to immediate embolectomy and surgical therapy (Sadiq and Ibrahim 2001).
In addition to the avoidability of surgical
therapy, the shortening of the patient’s length
of stay is another important advantage of
thrombin injection. More important than the
correct and timely therapy of the aneurysm
spurium, however, is its prevention through
specicity for the detection of arterio-venous
stulas, the ndings can be conrmed and a
loud buzzing can be detected by auscultation
(Kent etal. 1993a, b). However, the suspected
diagnosis of “vascular defect after arterial
puncture” also automatically entails imaging
by color-coded duplex ultrasound (Hruby
etal. 1989; Neise etal. 1998). Here, the presence of an arterio- venous stula reveals
turbulent ow between the artery and vein.
Many of the arterio- venous stulas found
close spontaneously within a year and without further intervention (Kent et al. 1993a,
b). Regular duplex sonographic follow-up is
appropriate with this approach (Perings etal.
2002). In addition, manual ultrasound-guided
compression is an easy-to-perform and effective therapeutic procedure with subsequent
reapplication of a pressure bandage (Zhou
et al. 2007). If this non-invasive approach
fails to close the arterio- venous stula, endovascular therapy with percutaneous insertion
of a covered stent is an option in addition to
open surgical therapy (Ruebben et al. 1998;
Thalhammer etal. 2000; Onal etal. 2004).
the correct puncture technique.
Retroperitoneal Hematoma
z
Arterio-Venous Fistula
z
Similar to the pseudoaneurysm after arterial
puncture of the groin, the arterio-venous stula also appears clinically, but often much
later in the time course. The incidence of
arterio- venous stula after cardiac catheterization is reported in the literature to be 0.22–
1% (Sidawy etal. 1993; Kron etal. 1985; Kelm
etal. 2002). The causes are either the simultaneous placement of arterial and venous
sheaths or puncture error with puncture of the
vein and artery without sufcient subsequent
compression and persistent tissue defect. A
puncture that is too deep is also associated
with a higher incidence of arterio- venous stulas (Altin et al. 1989). Other predisposing
factors include anticoagulation with Heparin
or Coumadin, puncture of the left-sided groin,
arterial hypertension, and female gender
(Kelm etal. 2002). Affected patients describe
localized pain and swelling around the puncture site. Such complaints by patients should
always be taken seriously. During the clinical
examination, which has a high sensitivity and
“Is arterial puncture dangerous?”—This
question was asked by Platts and Ridgway
more than 45years ago, describing a case of
retroperitoneal hematoma after puncture of
the left femoral artery for dialysis purposes
(Platts and Ridgway 1965). The answer to the
above question today must be “yes and no”.
Yes, because in the worst case it can lead to
a vascular defect that cannot be managed
conservatively or to a retroperitoneal hematoma. And no, because in the hands of the
skilled it represents an uncomplicated access
route to the arterial vascular system. For correct femoral puncture technique, see earlier in
this chapter. The incidence for retroperitoneal
hematoma after arterial puncture is reported
to be 0.45–0.74% (Maluenda et al. 2011;
Farogue etal. 2005) (.
Fig.2.8).
The serious retroperitoneal hematoma
must be distinguished from the supercial,
subcutaneously located and clinically insignificant hematoma following arterial puncture
of the right femoral artery. The supercially
located, either at or spherically encapsulated
A. und V. testicularis dextra
A. phrenica inferior
s
s
Colon sigmoideum
Procedural Complications
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Inferior V. cava
V. suprarenalis dextra
A. renalis dextra
Ren dexter
V. renalis dextra
33
sinistra
Glandula
suprarenalissinistra
Truncus coeliacus
V. suprarenalis
sinistra
A. superior
mesenterica
Aorta abdominalis
2
N. subcostalis
Ureter dexter
N. iliohypogastricus
M. psoas major
A. und V. iliaca
communis
N. ilioinguinalis
M. iliacus
N. cutaneus femoris
lateralis
N. genitofemoralis
The Tunica serosa and the Tela subserosa as
well as the Fascia transversalis and the
Muskelfaszien were removed.
. Fig. 2.8 Organs and pathways of the retroperitoneal space. (From Tillmann 2010)
hematoma causes a local pain in the area of
the groin around the puncture site. On palpation, the pain can be elicited or intensied. In
contrast, retroperitoneal hematoma presents
clinically quite differently. Local discomfort in
the area of the punctured groin may be absent
altogether (Lodge and Hal 1993). The pain
character is duller and is described as very
strong, but occurs with a time delay, making
early diagnosis difcult (Chan et al. 2008).
The pain, which is then severe, is due to the
peritoneal stimulus caused by bleeding in the
retroperitoneal space. The pain is much more
severe in intensity and localized in the ank
or back region. Because the retroperitoneal
space provides ample room for leaking blood,
patients are often noted for relevant hemoglobin drops and signs of incipient or manifest
volume- deciency shock. The combination of
abdominal pain, ank pain or back pain and
hemodynamic instability is highly suspicious
for a retroperitoneal hematoma and must
prompt adequate diagnosis and therapy.
The diagnostic tool of choice for verication of a suspected retroperitoneal
hematoma is computed tomography (CT)
or intra- arterial angiography (. Fig. 2.9).
Orientational abdominal ultrasound and
color-coded duplex ultrasound may be performed beforehand, but they should not
delay the conrmatory computed tomography. In case of negative ultrasound ndings
A. inferior
mesenteric
N.iliohypogastricu
Ureter sinister
N. ilioinguinalis
A. und V. testicularis
sinistra
N.cutaneus femori
lateralis
A. und V. sacralis
mediana
Plexus rectalis
superior
Vesica urinaria
34
E. Kaiser et al.
ture itself as well as the insertion of sheaths,
wires and devices. Hydrophilic or hydrophobic coated wires have a higher traumatic
2
potential than non-coated wires. Whenever
such a foreign body comes into contact with
the vessel wall, vascular wall injury can
potentially occur. The incidence of dissection of the arterial access pathway is 0.42–
0.68% (Prasad etal. 2008; Muhs etal. 2005).
This is even more the case when sheaths and
devices with larger and very large diameters
are used, such as those used in most interventions for structural heart disease. For
. Fig. 2.9 CT retroperitoneal hematoma
example, in the early days of transfemoral
percutaneous aortic valve replacement, iliac
but urgent clinical suspicion of retroperitoneal hematoma, CT must follow in any case.
Independent predictors for the occurrence of
a retroperitoneal hematoma are too high arterial puncture, female gender, low body surface
area and the presence of chronic renal insufciency, whereas the use of GPIIbIIIa receptor antagonists and the use of closure systems
had no inuence on the occurrence of a retroperitoneal hematoma (Farogue etal. 2005;
Tiroch et al. 2008). The investigation of an
inuence of the size of the arterial sheaths
used leaves different results.
The therapeutic approach depends on the
severity of the bleeding and the hemodynamic
instability. Patients with retroperitoneal
hematoma are hemodynamically monitored
in the ICU with invasive arterial blood pressure measurement and measurement of central venous pressure. These measures help in
volume management. If patient stabilization
can be achieved by transfusion with red blood
and femoral dissections were observed in
about 10% of cases (Kahlert et al. 2009).
Today, the delivery systems are much
smaller, so that the complication rates have
also been signicantly reduced. The respective situation is particularly complicated by
pre-damaged vessels, calcications or severe
kinkings in the area of the access path, since
the passage of each curvature is accompanied by increased friction of the device on
the vessel wall. Passage of vascular stenoses
is also always associated with an increased
risk of vascular dissection and rupture. The
occurrence of local vessel wall dissection or
vessel rupture does not necessarily imply a
worsening of patient outcome (Hayes etal.
2002). During retraction of wires, catheters,
devices and sheaths, the punctured vessel
must also be subsequently checked for vessel wall defects, as dissections, ruptures or
lacerations can also occur during retraction
(.
Figs.2.10 and 2.11).
cell concentrates, crystalloid and plasmaexpanding infusion therapy, and sufcient
pain management, interventional or surgical therapy is not required. For patients who
cannot be stabilized in this way, endovascular
techniques with implantation of a stent graft
> Increased caution or a change of strategy is
required if increased resistance is encountered when advancing sheaths, wires or
devices. The position may not be intraluminal, but intramural or extravascular.
or open suturing of the vascular defect are
available (Chan etal. 2008).
The therapy of vessel wall defects, be it complex dissections or relevant perforations or
Dissections and Perforations of the
z
Inguinal Vessels
The vessel wall defects in the area of the
arterial access path up to the aortic bifurcation can usually be traced back to the punc-
vessel ruptures, consists rst of all in the
application of an occlusive balloon to push
back the dissection or seal the vessel wall
defect. Dissections do not necessarily have
to be stented. Stent implantation should be
Procedural Complications
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. Fig. 2.10 Iliac dissection
35
> For femoral access procedures, occlusion
balloons of various sizes should always be
kept in the cath lab’s consignment stock.
Practical Tip
The correct puncture technique and the
insertion of large-calibre sheaths can
now be trained very elegantly on the
CardioSkills SmartPuncture Simulator
(.
Fig. 2.12). The simulator has a vessel
model with different vessel morphologies as
well as pulsatile ow, so that punctures in
complex anatomies and difcult circulation
conditions can also be trained (7
cardioskills. com). The “number needed
to TRAIN” is 4, so in order to avoid one
vascular access site complication four simulated cases need to be performed.
www.
2
. Fig. 2.11 Iliac dissection after stenting
avoided, especially in the motion segments.
Surgical repair of the vessel wall defect is the
best option here. Outside of motion segments,
stent implantation is the method of choice for
dissections that threaten to occlude the vessel. If there is a relevant perforation, rupture
or even laceration of the vessel, an occlusion
balloon is rst advanced over the intraluminal
wire and inated. Afterwards, it will have to
be decided whether implantation of a covered
stent is possible or whether the vascular defect
must be surgically repaired.
2.1.2 Radial Access
Today, access via the radial artery should be
chosen as the standard access route for coronary diagnostics and most coronary interventions. Compared with access via the groin with
puncture of the femoral artery, access via the
radial artery does not differ fundamentally,
but it does differ in some points worth considering (. Fig.2.13). In particular, the fact that
the radial artery has a smaller diameter than
the common femoral artery and is very prone
to spasm in response to tactile stimuli has an
impact on the clinical procedure when using
the radial artery approach. In addition, special
attention is required when the patient expresses
pain, so as not to overlook an antegrade perfusion disturbance (spasm, see below).
Topographic Anatomy
z
The radial artery lies very supercially in the
region of the carpus and is easy to palpate
here. Together with the ulnar artery, it represents the metacarpal and nger perfusion
via the deep palmar arch. The ulnar artery
is also very supercial on the ulnar side in
the carpal region and is easy to palpate
(. Fig.2.14).
36
E. Kaiser et al.
. Fig. 2.12 The
CardioSkills SmartPuncture Simulator
2
access of rst choice for diagnostic cardiac
catheter examinations, elective and also acute
interventions and is now also recommended
in the guidelines. The advantages of the ease
of compressing the radial artery after the
procedure and the rapid mobilization of the
patient are offset by a pronounced tendency
to spasm of the radial artery and brachial
arteries in general. These spasms must be controlled with medication in some patients in
order to make the examination via the radial
artery possible and tolerable for the patient.
Due to its smaller vessel calibre, the radial
artery is prone to pronounced vascular spasms,
especially in smaller women. Spasms during the
examination are by far the most frequent complication of radial access, especially at the beginning of the learning curve. They can be so severe
that the catheter or sheath can no longer be
moved and retracted. The use of force here can
result in signicant injury to the patient, such as
a tear or eversion of the radial artery. In this sit-
. Fig. 2.13 Puncture site radial artery
Further proximally, there is another good
access route to the arterial vascular system via
the larger calibre brachial artery. It runs along
the medial upper arm, covered only by skin,
subcutaneous fat and fascia (. Fig.2.15).
Spasm
z
The radial access route is now correctly considered by many interventionalists as the
uation, local or systemic vasodilating measures
are often no longer successful and occasionally
contraindicated, as many patients react vagally
due to the strong pain stimulus. The most promising measure in this situation is therefore deep
sedation or even anaesthesia of the patient.
In my personal experience, all catheters and
sheaths could be removed without injury.
Predisposing factors for a radial spasm
are: the agitated or pain-stricken patient,
a small radial diameter, a sheath that is too
es
Aa. digital palmares
Procedural Complications
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A. radialis
R. carpalis
palmaris
R. palmaris
superficialis
37
Ast der A. interossea anterior
A. ulnaris
R. carpalis dorsalis
R. carpalis palmaris
2
Arcus palmaris profundus
A. princeps pollicis
Aa. Metacarpales palmaris
A. radialis indicis
Perforating Rr.
proprii pollicis
R. palmaris profundus
Arcus palmaris
superficialis
Aa. digital palmares
communes
Aa. digital palmar
propriae
. Fig. 2.14 Arteries of the hand, right side. View from palmar
large in relation to the vessel diameter, pronounced radial loops or severe kinking in the
vessel course, and frequent catheter manipulations, which are particularly necessary at the
beginning of the learning curve.
Avoidance strategies can already be derived
from this: sedation of agitated patients plays
a very important role; in my opinion, even
routine sedation is recommended for inexperienced examiners. The examination of very
small patients at the beginning of the learning curve should be avoided or, if unavoidable,
rather performed with a small sheath. Passage
of loops and kinkings is facilitated by the use
of hydrophilic or thinner wires (0.018 in.) and
visual control; however, the C-arm must often
be rotated for this purpose; a forced approach is
not recommended. The use of sheathless hydrophilic coated guiding catheters may improve the
size ratio of the catheter to the vessel compared
to a conventional sheath, but care must be
taken to avoid increased catheter movement in
the vessel due to movement of the sterile covered arm. The advancement of a guiding catheter in cases of spasm tendency or calcications
can be simplied by making the transition from
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